• Known diabetes history

• Changes in mental function

• Excessive urination

• Increased thirst

• Nausea and vomiting

• Low blood volume

• Capillary glucose check

• Insert two large-bore IV lines

• Laboratory tests: serum glucose, arterial/venous blood gases, basic metabolic panel, serum osmolality, ketones in serum and urine, beta-hydroxybutyrate, HbA1c

• Elevated anion gap > 10 mEq/L

• Serum bicarbonate under 18 mEq/L

• Glucose typically above 250 mg/dL

• Strongly positive urine/serum ketones

• Increased serum β-Hydroxybutyrate

Diabetic Ketoacidosis (DKA)

• Normal anion gap < 10 mEq/L

• Serum bicarbonate greater than 18 mEq/L

• Glucose usually exceeds 600 mg/dL

• Serum osmolality above 320 mOsm/kg

• Negative or mild urine/serum ketones

• Normal serum β-Hydroxybutyrate

Hyperosmolar Hyperglycemic State (HHS)

Prepare 100 mmol sodium bicarbonate in 400 mL water with 20 mEq potassium chloride; infuse 200 mL/hr for 2 hours

Repeat every 2 hours until blood pH rises above 7.0

• Initial bolus: 0.1 U/kg, followed by continuous infusion at 0.1 U/kg/hr

• Alternatively, no bolus with infusion at 0.14 U/kg/hr

Target glucose reduction: 50–75 mg/dL per hour, maintaining 150–200 mg/dL (DKA) or 200–300 mg/dL (HHS) until stabilization

Bolus: 1 L over 1 hour if systolic BP > 90 mmHg; 500 mL over 15 minutes if systolic BP < 90 mmHg

2. If serum potassium < 5.3 mEq/L: supplement IV potassium (20–30 mEq/hr), maintain levels around 4–5 mEq/L

3. If serum potassium < 3.3 mEq/L: give IV potassium first, then proceed to step 1

Monitor: pH, blood glucose, anion gap, ketones, potassium, calcium, magnesium, phosphate

Serum glucose target ≤ 200 mg/dL

Monitor: glucose, osmolality, neurological status, potassium, calcium, magnesium, phosphate

Serum glucose target ≤ 300 mg/dL

• Glucose below 200 mg/dL

• Plus at least two of:

o Venous pH above 7.3

o Serum bicarbonate ≥ 15 mEq/L

o Anion gap ≤ 12 mEq/L

• Serum osmolality under 320 mOsm/kg

• Normal neurological status

• Glucose between 250–300 mg/dL